Health Inequities in the UK Healthcare System
Emigrating from Kenya to the United Kingdom and being a science student, has made me so engrossed in the topic of healthcare. Both as a whole system and specifically the issue of access to healthcare. Being born into an environment that conflates a basic necessity of life with luxury and then growing up in another place where this necessity was free for all, made me confused. It should only make sense that societies are alive and healthy in order to thrive to their full potential, which in turn maximises the economy, and the cycle continues. When this basic need is minimised, you see the society begin to breakdown. In 2017, it was estimated that over 100 million people live in poverty due to high health expenses (1). It is easy to pin-point this lack of access as a major problem for undeveloped countries and even ‘first world’ countries such as America in which healthcare is not free. However, if you look closely, you will be able to see the cracks in the system in countries that have an established free healthcare service. Let us take a look at the United Kingdom who deployed the National Health Service (NHS) in 1948 and yet, 72 years later, the health of certain individuals and families are not protected adequately.
The NHS: History and its focus through time
A century before the inception of the NHS, the first ever public health law ‘The 1848 Public Health Act’ was passed to improve health at local levels. The act’s main purposes were to improve drainage, rubbish collection and access to clean drinking water. Healthcare then evolved and larger crises fuelled mass immunisation, education on nutrition and preventative healthcare (2). The NHS is a commendable service and its existence has been proven to largely benefit the population’s economy and overall health over decades. However, the system is catered to improve the healthcare of its citizens with the assumption that personal lifestyle choices and behaviours (i.e. smoking, alcohol consumption, level of exercise, diet/nutrition etc.) determine the presence of illness (3). Throughout time, despite various recommendations and attempts, health equity has remained inappropriately unaddressed as a major contributing factor to illness and access to healthcare.
How the socioeconomic determinants affect health
Income, occupation, education and environmental exposure all contribute to the health of an individual both directly and indirectly (4). These determinants cannot simply be improved by making ‘different’ choices as carefully constructed ideals of capitalism make escaping poverty impossible for certain demographics. In 2008/09, 16.2 million people (26.8% of the population) were living in homes that did not make the minimum income as advised by the government that was sufficient to live. 10 years later, this number rose to 18.7 million (28.9%) people. This issue is particularly prevalent in Bangledeshi, Black and Pakistani ethnic groups which on average have 46% of their demographic, living below the minimum household income which on average is 18% more than other groups, with the White population being the least deprived (5). Even now during the Covid-19 pandemic, we see Black and ethnic minorities having a disproportionately higher risk of becoming infected with the virus and dying as a result of infection. This is not a consequence of a biological difference, but instead of the socioeconomic factors related to these demographics. These factors cause an increased exposure to the pathogen in working and living environments (as BAME individuals make up ~40% of the key worker workforce and living in more densely populated areas) and racial injustice preventing the patients having their health concerns dealt with the seriousness required (6). Let's not forget the historical and racial context in which healthcare systems were built.
A lower income determines how individuals heat their home, how well they can feed and dress themselves, their job security and their life expectancy. Fuel poverty (spending more than 10% of the income on heating the home adequately) results in an increased number of winter deaths which are attributed to cold homes or the onset of cardiovascular disease or respiratory diseases, which can be a consequence of, or exacerbated by cold environments (7). In Sir Michael Marmot’s first paper ‘Fair Society, Healthy Lives’, it was reported that 25% of adolescents that lived in cold housing for 3-5 years are more likely to experience mental health issues in comparison to 4% of adolescents living in warmer housing (8). Fuel poverty can be solved or prevented by the installation of proper wall cavity and floor insulation in all homes, which can be seen in other countries such as Sweden (8,9).
Looking further into socio-economic deprivation, the link between poverty and life expectancy become extremely clear. In 2016-18, the ‘healthy life expectancy’* age gap between those living in the most deprived areas and the least deprived areas in Scotland is 23.1 years for men and 23.9 years for women (10). In England, the ‘healthy life expectancy’ age gap for men and women is 18.9 and 19.4 years, respectively, when comparing deprivation in areas of the country (11).
*The healthy life expectancy is the number of years a person is expected to live in ‘good health’, thus if you live in a less deprived area you have longer to live with your health intact (12).
The Funding Model of the NHS
The NHS is publicly funded through tax payments (accounting for ~85% of funding) and can be topped up with National Insurance Contributions (~24%) and patient charges (~1%). Spending on the NHS is almost eleven times more than it was in 1948, taking inflation into consideration. Even with increased spending, the rate of spending growth has dropped significantly in the past decade to 1.1%/year of increased spending from an average of 3.7%/year, before 2010, making it the most severe period of cuts since 1948. More interestingly, the highest increase in NHS spending was seen during the Labour government in 2001/02-2004/05 at an average of 8.9%/year and one of the lowest growths in history was during the Conservative-Liberal Democrats coalition government at an average of 1.1%/year. The same growth rate of 1.1% is predicted to be in effect under the Conservative government we have now, led by Boris Johnson (13).
With the decrease in spending growth, threats of healthcare privatisation and a decreased or stagnant increase of the number of employed medical health professionals (14), the NHS is under enormous stress to function effectively, to cater to the increased demand of a growing and ageing population (15). It is imperative that health equity is discussed as a major concern, due to its obvious importance to preventing the number of health issues that occur in the population.
I hope that now you see that free healthcare alone is not enough to tackle health inequities. Of course, the UK would not be able to function to the level it has without the NHS and I for one have benefitted immensely. To help the NHS work to its full potential, there has to be specific government policies put in place to protect those who are vulnerable. One’s health should never be compromised just because of the demographic they were born into and where they live. Even if you can or will be able to afford private healthcare in the future, think about those who cannot survive even with free healthcare. Vote responsibly and with empathy.
You can view the references used for this post below.
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Until next time,